Nokea
The nurse in labor and birth is caring for a Muslim patient during the active phase of labor. The nurse notes that the patient quickly draws away when touched. Which intervention should the nurse implement?
- A. Ask the charge nurse to reassign you to another patient.
- B. Assume that she does not like you and decrease your time with her.
- C. Continue to touch her as much as you need to while providing care.
- D. Limit touching to a minimum because physical contact may not be acceptable in her culture.
Correct Answer: D
Rationale: The appropriate intervention for the nurse to implement in this situation is to limit touching to a minimum because physical contact may not be acceptable in the patient's culture. In Islam, modesty and privacy are significant aspects of the faith, and physical contact, especially with someone of the opposite gender, may be considered inappropriate or uncomfortable for the patient. Respecting and acknowledging the patient's cultural background and preferences is essential in providing culturally competent care. Therefore, it is important for the nurse to be mindful of the patient's boundaries and minimize any unnecessary physical contact while still providing necessary care and support during labor.
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What type of mastectomy removes the entire breast but leaves the chest wall intact?
- A. total simple mastectomy
- B. modified radical mastectomy
- C. skin-sparing mastectomy
- D. nipple-sparing mastectomy
Correct Answer: A
Rationale: A total simple mastectomy is a type of mastectomy that removes the entire breast, including the breast tissue, nipple, and areola, but it leaves the chest wall muscles intact. In this procedure, the lymph nodes under the arm (axillary lymph nodes) are not typically removed. The total simple mastectomy is usually performed when the breast cancer is small and localized, and there is no evidence of spread to the surrounding lymph nodes or chest wall. This surgery is considered less extensive than other types of mastectomies, such as modified radical mastectomy, skin-sparing mastectomy, or nipple-sparing mastectomy, which involve different levels of tissue removal.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- A. Increase potassium intake.
- B. Increase fluid intake to 3 liters per day.
- C. Decrease sodium intake before menstruation.
- D. Decrease daily fiber intake.
Correct Answer: C
Rationale: Reducing sodium intake can help decrease fluid retention and reduce breast discomfort associated with fibrocystic breast changes.
During which phase of the cycle of violence does the batterer become contrite and remorseful?
- A. Battering
- B. Honeymoon
- C. Tension-building
- D. Increased drug taking
Correct Answer: B
Rationale: During the cycle of violence, the batterer displays contrition and remorse during the Honeymoon phase. This phase follows the Battering phase, characterized by the abusive behavior and violence, and precedes the Tension-building phase where stress and tension begin to escalate. The Honeymoon phase is marked by the abuser showing remorse, apologizing, and trying to make amends for their violent behavior. This phase often involves the abuser being extra charming, affectionate, and demonstrating efforts to reconcile with the victim. It is important to note that the Honeymoon phase is often temporary and is part of the cycle that may repeat unless intervention and support are sought.
A nurse educator is teaching a group of nursing students about the history of family-centered maternity care. Which statement should the nurse include in the teaching session?
- A. The Sheppard-Towner Act of 1921 promoted family-centered care.
- B. Changes in pharmacologic management of labor prompted family-centered care.
- C. Demands by physicians for family involvement in childbirth increased the practice of family-centered care.
- D. Parental requests that infants be allowed to remain with them rather than in a nursery initiated the practice of family-centered care.
Correct Answer: D
Rationale: The statement that parental requests that infants be allowed to remain with them rather than in a nursery initiated the practice of family-centered care is the most accurate regarding the history of family-centered maternity care. Family-centered care evolved in response to the recognition of the importance of family involvement in maternity care and the benefits of promoting bonding between the newborn and their parents. This shift in practice came about in response to increasing parental requests for infants to remain with them rather than being separated in a nursery setting. This marked a significant departure from traditional policies that separated mothers and infants after birth and paved the way for the development of family-centered approaches to maternity care.
The nurse is assessing a 33-year-old female patient who comes to the family practice clinic with complaints of excessive menstrual bleeding with bleeding between periods for the past 6 months. The health care provider has performed an endometrial biopsy and has discontinued the patient's oral contraceptives. What is the rationale for this treatment?
- A. This condition is often associated with use of oral contraceptives and may subside upon discontinuation.
- B. This condition is often associated with type 2 diabetes and must be controlled with a different type of birth control.
- C. This condition is often associated with hyperplasia of the endometrial tissue, which is exacerbated with oral contraceptives.
- D. This condition is often associated with ovarian cysts, which are exacerbated with the use of oral contraceptives.
Correct Answer: C
Rationale: The correct rationale for discontinuing the oral contraceptives in a patient with excessive menstrual bleeding and bleeding between periods is that this condition is often associated with hyperplasia of the endometrial tissue, which can be exacerbated with the use of oral contraceptives. Endometrial hyperplasia is a condition characterized by the abnormal thickening of the lining of the uterus, which can lead to heavy or prolonged menstrual bleeding. Estrogen contained in oral contraceptives can contribute to this thickening of the endometrial tissue, potentially worsening the patient's symptoms. By discontinuing the oral contraceptives, the provider aims to reduce the estrogen levels in the body, which may help alleviate the symptoms associated with endometrial hyperplasia. An endometrial biopsy is also important in this case to further investigate the underlying cause of the abnormal bleeding.